High Incidence of Cough among Users of Angiotensin-Converting Enzyme Inhibitors

Objective: To evaluate the incidence of cough among patients newly diagnosed with hypertension initiated on Angiotensin-Converting Enzyme Inhibitors [ACEI]

Design: A Prospective Study

Setting: Two primary healthcare centers, Bahrain

Method: Newly diagnosed patients with hypertension who were initiated on ACEI or angiotensin receptors blockers [ARBs] were included in the study. The patients were followed for one year starting from 2 January 2016 to 31 December 2016. The following data were documented: age, sex, smoking, body mass index [BMI], and concomitant co-morbid diseases, the onset of cough, duration, drug discontinuation, and the cough disappearance after discontinuation

Result: Eighty patients were included in the analysis. Sixty-five [81%] patients received ACEI and 15 [19%] were on ARBs. Forty-three patients (54%) were females. Cough developed in 24 [37%] patients. Perindopril was the only ACEI prescribed. The mean cough onset is 12.7 days. After stopping or changing the drug, the mean for cough disappearance was 13.3 days. There was a statistically significant gender difference in ACEI-induced cough. Cough developed in 17 [70.8%] females compared to 7 [29.2%] males; P=0.044. There was no significant difference regarding age [P=0.79] or BMI [P=0.37]

Conclusion: The incidence of cough is unexpectedly high among our newly diagnosed hypertensive patients initiated on Perindopril. It is much higher among females. Larger study is needed to examine this common, often intolerable, adverse effect

Lipohypertrophy among insulin-treated patients

Objective: To evaluate insulin injection practice, prevalence and risk factors of lipohypertrophy [LH] among insulin-treated patients

Design: A Retrospective Study

Setting: Two Primary Health Centers, Bahrain

Method: Ninety-five insulin-treated patients were included in the study from 3 January 2016 to 31 May 2016. The following data were documented: age, sex, educational level, type of diabetes, duration of diabetes, duration of insulin treatment, number of injections, type of insulin, daily insulin dose, needle size, site of injection, frequency of needle change, frequency of injection site rotation and frequency of checking the injection site. Diabetes control and Body Mass Index [BMI] were documented. Ultrasound examination of the injection site was performed

Result: Ninety-five insulin-treated patients were included in the study

Thirty-five [36.8%] patients had LH. Seventy-two [75.8%] patients were obese females with poorly controlled type 2 diabetes

Forty-seven [49.5%] patients were using insulin for less than five years. Ninety-three [97.8%] patients were using <6 mm needle; 85 [89.5%] were using the needle once at a time and were doing daily rotation

The injection site was never checked in all except one [1.1%] patient

There was a highly significant statistical association between LH and level of education, the number of injections and the site of injection. Mean subcutaneous fat thickness were 12.3 mm [arm], 17.8 mm [thigh] and 23.3 mm [abdomen]

Conclusion: Lipohypertrophy is prevalent among our patients and could be related to improper insulin injection technique and lack of regular check of the injection sites. Therefore, patients and health providers' education is necessary to reduce its prevalence

Control of cardiovascular risk factors among people with diabetes: evaluation revisited

Objective: To assess control of hyperglycemia, hypertension and dyslipidemia among patients attending diabetes clinic in 2014 compared to 2005

Design: A Cross-Sectional Study

Setting: Primary Health Center, Ministry of Health, Bahrain

Method: Medical records of patients attending diabetes clinic from 1 September 2014 to 31 December 2014 were reviewed. Data documented were age, sex, diabetes duration, Body Mass Index [BMI], smoking, glycated hemoglobin [A1C], oral hypoglycemic drugs and insulin regimen, blood pressure, antihypertensive drugs, lipids profile and statin type

Result: Three hundred seventy patients' records were reviewed. One hundred-thirty [35.1%] patients were males. Two hundred four [55.1%] patients were having diabetes for more than or equal to 15 years. Glycated hemoglobin < 53 mmol/l was achieved in 92 [24.9%] patients in 2014 compared to 134 [20.4%] patients in 2005 [P-Value=0.1]. Blood pressure

Conclusion: Significant improvements have been observed in control of the studied CV risk factors in 2014. However, control of hyperglycemia remains a challenge and needs to be improved

Risk for obstructive sleep apnea among people with diabetes

The aim of this study is to identify people at high risk for Obstructive Sleep Apnea [OSA] and to evaluate the impact of OSA on the control of cardiovascular risk factors. Design: A Cross-Sectional Study. Setting: Four Primary Health Care Centers. Method: Patients attending diabetes clinics in four health centers were screened for OSA by using the Berlin questionnaire. In addition, patients' medical records were reviewed for age, sex, body mass index [BMI], blood pressure, glycated hemoglobin, lipid profile, antihypertensive, hypoglycemic agents and previous OSA diagnosis. Result: A total of 455 questionnaires were analyzed. All patients included were type 2. The mean age was 56.6 years. High risk for OSA was present in 173 [38%] patients. It was more common among females [P=0.013]. There was no significant age difference [P=0.75]. The risk of OSA increased significantly with BMI >/= 35 [P<0.001]. No significant difference was found between low and high risk in the control of glycated hemoglobin, lipid profile, and the number of drugs used. Three [1.7%] patients from the high OSA risk and 2 [0.71%] from the low risk [282] had previous OSA diagnosis. Conclusion: More than one-third of our patients were high risk for OSA. Screening for OSA among diabetics is lacking despite the presence of high number of at risk patients. Increasing awareness of the treating physicians is needed

Risk factors for diabetic retinopathy in patients attending primary care settings

To identify risk factors for diabetic retinopathy [DR] among patients with diabetes attending primary care health centers and to assess level of control. Case control study. Twenty-two health centers. The medical records of patients with diabetes who were screened for retinopathy during the year 2011 were reviewed. The following were documented: age, sex, duration of diabetes, glycated hemoglobin [A1C], blood pressure [BP], lipid profile, smoking status, presence or absence of chronic kidney disease and guardian drugs [Angiotensin Converting Enzyme Inhibitors [ACEi], Angiotensin Receptor Blockers [ARBs], Statins and Aspirin] used. In addition, patients with diabetes who were screened as normal [no DR] from 4 health centers were randomly selected and their medical records were reviewed to compare the above mentioned risk factors between those with and those without DR. A total of 1,508 retinal screening forms were reviewed, 112 patients were diagnosed with DR. A total of 263 screened but had no DR were reviewed in the selected 4 health centers. In DR, uncontrolled A1C was found in 81 [72.3%] patients, high BP in 69 [61.6%] and Low Density Lipoprotein in 81 [72.3%]. There was statistically significant association between A1C >/= 53mmol/mol [P=0.000], increased diabetes duration [P=0.000], total cholesterol >/= 5.2mmol/l [P=0.008], LDL >/= 2.6mmol/l [P=0.002] and the presence of DR. There was no significant association between age, sex, BP, and triglycerides level >/= 1.7mmol/l and presence of DR. The use of statins, ARBs, fibrates and aspirin was significantly higher in patients with DR. Control of the identified modifiable risk factors is suboptimal. The burden of DR can be reduced by more intensive control of these factors through effective use of the currently available guardian drugs

Dyslipidemia among people with diabetes: control and pattern of prescribing

To evaluate lipid control and drugs used in the management of diabetic people with dyslipidemia. A retrospective clinical study. NBB Dair Health Center. Copies of prescriptions for people with diabetes from 2 January 2011 to 30 April 2011 were retrieved. Prescriptions containing anti-lipid medications were screened. The charts of these patients were reviewed. Data collected include age, sex, lipid profile, drug used and its dose, compliance with liver enzymes monitoring and their levels and the use of combination drugs. In addition, the total number of visits made by the patients during 2010 was documented. Four hundred twenty-six patients were included in the study. Two hundred sixty [61%] were females. Two hundred fifty-five patients [59.8%] achieved LDL <2.6 [<100 mg/dL]. Triglycerides target [<1.7; <150 mg/dL] was achieved in 247 [58%] patients. HDL target [>1; >40] was achieved in 297 [69.7%] patients; one hundred thirty-three patients [31.2%] achieved these three targets. Two hundred thirty-three patients [55%] were using either Pravastatin 20 mg or Simvastatin 20 mg. Four patients [0.94%] were on combination of a statin and Bezafibrate. No significant gender difference in the level of control and statins doses was found. The study revealed that the management of dyslipidemia among people with diabetes is suboptimal. Using moderate to high potency statins and/or combination is needed to increase the number of patients who meet guidelines recommendations

Prevalence of peripheral arterial disease among people attending diabetes clinics at primary care settings

The aim of this study is to use ankle-brachial index [ABI] to evaluate the prevalence of peripheral arterial disease [PAD] in diabetic patients and to identify the associated cardiovascular risk factors and their level of control. Cross-sectional Study. Four primary healthcare centers. Four health centers were chosen randomly. People attending diabetes clinics were screened for PAD by measuring their ABI. ABI /= 3 CKD [P=0.014]. Use of statins was lower in patients with PAD when compared with patients with normal ABI [P=00]. The study revealed that PAD is highly prevalent among people with diabetes. Control of cardiovascular risk factors was poor in general, but was worse in patients with PAD. The use of guardian drugs was suboptimal

Hypertension in a primary care setting: control and pattern of prescribing

To measure the level of blood pressure control among people with hypertension attending National Bank of Bahrain Health Center at Dair [NBB Dair] and to evaluate the pattern of prescribing by the treating physicians. A retrospective clinical study. NBB Dair Health Center. The prescriptions of patients with chronic diseases from 1st of April till 30th of June 2009 were reviewed. All prescriptions of antihypertensive agents were included in the study. In addition, the patients' records were reviewed. The following data were recorded: recent blood pressure [BP] reading, presence of co-morbidities, dosage of drugs used and current regimen. Controlled hypertension is defined as systolic less than 140 mmHg and diastolic less than 90 mmHg in the absence of diabetes and/or Chronic Kidney Disease [CKD]. BP less than 130/80 is used to define controlled BP in the presence of these conditions. Five hundred and seventy-three prescriptions were included in the study. Females constituted 61.6% of the total sample. About half of the patients 272 [47.5%] had concomitant diabetes and/or dyslipidemia. The overall control rate was 35.8%; it dropped to 26.6% in patients with diabetes. Gender difference was found in the level of control [P=0.00002]. It was better in females, but was poor among patients above 60 in both sexes. Thirty-four percent of the patients were using a single free drug. The use of fixed drug combination was uncommon in the studied population. Although BP control among the studied population is better than that found in several hypertension surveys, the control level is still far from ideal and it is important to improve it to reduce the burden of cardiovascular diseases and its complications

Prevalence of depression among people with diabetes attending diabetes clinics at primary health settings

To study the prevalence of depression among diabetics and to examine the relationship between depression and socio-demographic factors, metabolic control and diabetes complications. A Cross-Sectional Retrospective Clinical Study. Four Primary Health Care Centers. Two hundred and sixty-four patients were surveyed for the presence of depressive symptoms using Beck Depression Inventory [BDI] scale. In addition, patients' records were reviewed to abstract the following data: socio-demographic characteristics including: age, sex, marital status, level of education, smoking status, Body Mass Index [BMI], duration of diabetes, control of diabetes, use of insulin, presence of diabetic complications, presence of co-morbid conditions including hypertension and hyperlipidemia and the use of antidepressant[s]. Eighty-eight patients [33.3%] scored 16 or more on BDI scale. One hundred and sixty patients [60.6%] of the total sample were females. Statistical significant association was found between high BDI score [>/= 16] and sex, obesity [BMI >/= 30kg/m[2]], nephropathy, ischemic heart disease, and the use of insulin. No significant association between BDI score and metabolic control, duration of diabetes, other socio-demographic factors and diabetic complications was found. It was found that only 6 [2.3%] patients were on antidepressants. Although about one third of the screened patients were potential cases of depression, the great majority were under-recognized and undertreated. Hence, psychosocial assessment should be part of initial and ongoing evaluation of these patients to improve their quality of life and decrease adverse outcomes

Evaluation of diabetes care in a primary care setting

To assess the level of control of diabetes among people seen in the diabetes clinic and in a general clinic. A retrospective clinical study. Isa Town Health Center. The records of 996 patients with diabetes were randomly selected and reviewed for screening of macrovascular and microvascular complications. The following parameters were screened: lipids, blood pressure [BP], glycated haemoglobin [HbA1C], neurovascular foot assessment, smoking, referral for retinal examination, and urine screening for albuminuria and/or proteinuria in the period from 1.3.2006 till 15.6.2006. One hundred thirty-four patients [13.5%] had HbA1C less than 7; one hundred thirty-seven patients [13.7%] had BP less than130/80; three hundred and fifteen patients [31.6%] were on statins; forty-two [13.5%] of the patients who were on statins achieved the Low Density Lipoprotein [LDL] target level; one hundred sixty-four [16.5%] patients who were above 40 years received aspirin; three hundred and eighteen patients [31.9%] were referred for retinal examination; urine screening was done for three hundred thirty-three patients [33.4%]. A highly significant statistical difference between the general and diabetes clinic was found in screening for all macrovascular and microvascular complications; with the exception of HbA1C, there was also a highly significant difference in metabolic and BP control among patients seen in diabetes versus general clinic. Neurovascular assessment of the feet was missing in the records reviewed in the general clinic. Referral for retinal screening is very low especially in patients seen in the general linic. The level of metabolic and BP control is low in both the general and diabetes clinic

use of herbs among people with diabetes in the Kingdom of Bahrain

The use of Complementary and Alternative medicine [CAM] is increasing worldwide and herbs are one of the most common types of CAM used. The aims of this study were to measure the prevalence of the use of herbs among people with diabetes in the Kingdom of Bahrain and to examine the relationship between certain demographic characteristics and the use of herbs. A cross-sectional survey was conducted on people with diabetes who attended 4 main health centers in four different health regions namely: Esa Town, Naim, Sitra, and National Bank of Bahrain Health Centers over a two months period [from 30[th] October till 31[st] December 2004] using a prepared questionnaire. 300 patients were surveyed. 43.7 percent of the patients were using herbs over the last one year. Statistically significant relationship between the duration, nationality, control of blood sugar, and complications of diabetes and the use of herbs was found. 74 percent of the patients did not disclose the use of herbs to their doctors. 29 types of herbs were used either alone or in multi-ingredient preparations. The most commonly used herb was bitter gourd [karela]. More than 30 percent of the patients did not know the name[s] of the herb[s] they were using. More than 60 percent got their herbs from friends or their relatives. The use of herbs by people with diabetes is common in the Kingdom of Bahrain. Increasing the awareness of the physicians to ask about herbs in their management of the disease and people in the community with health education is necessary as these herbs may have herb-drug interaction